Pages

Friday, June 29, 2012

"Collateral damage: the effect of
patient complications on the surgeon's psyche" was a brief but interesting
paper that probably went unnoticed by many. Using the results
of a survey completed by only 123 of the 403 surgeons who received it, the
paper studied the effect of complications on the emotional well-being of
surgeons. You could argue that the response rate of 30.5% renders the
conclusions suspect. But that’s not the point.

The subject matter hits close to home for any
surgeon who cares about his patients and what he does to them.

There are two types of complications—those
that happen despite your best efforts, such as a postoperative MI in a
seemingly healthy patient or an infection that develops after proper surgical
technique and appropriate antibiotic prophylaxis were used.

Then there are the complications that occur
because you made a mistake. Examples of this are sepsis due to an anastomotic
leak due to your well-intended but erroneous judgment that the patient’s bowel
wall would hold the staples or your failure to operate soon enough on a patient
with a bowel obstruction.

Of course when any complication occurs, we
feel bad for the patient and the family. But the latter type of complication
can keep you awake at night, undermine your confidence and your ability to
function and even effect your enjoyment of life in general. Eventually, you get
over it and move on, but the next time is no easier. According to the survey,
about two-thirds of the surgeons felt it was difficult to deal with the
emotional aspect of complications throughout their careers and experience
did not seem to lessen the impact.

Not everyone is affected in the same way or
to the same degree. I once had a surgeon tell me, “I’ve been in practice for 22
years, and I’ve never made a mistake.”

But for us mere mortals, mistakes happen and
leave scars. A South African blogger named Bongi said it much better than I in
a post he called “The Graveyard.” In it, he describes a
case of his with a delayed diagnosis that resulted in a patient’s death. He
said every surgeon has a graveyard in the “dark recesses of his mind” where
“names engraved on the tombstones” can be recalled.

I have a graveyard. I think most doctors do.

Note: This post appeared on Sermo yesterday and generated some thoughtful comments.

Wednesday, June 27, 2012

What is going on in schools today? No, I’m not talking about what seems to be an epidemic of teachers having sex with students. That’s old news.

Recently, there have been more examples of what I can only call an
inexplicable lack of common sense on the part of teachers and others at
schools. I have blogged about this before when school officials in New York attempted to ban words that might upset some students.

A six-year-old boy, accused of being a bully, was deemed by his teacher to need remediation. A second teacher was consulted. She had the perfect solution--have all the other students in the class repeatedly punch him. Another teacher reported the incident. The child’s mother was not happy. Here is the response of a school official from TV station KENS. “Steve Linscomb, a spokesperson for the district, confirms that the teacher will not be hired again within the school district, but suggests the incident was a result of a lack of experience. ‘This teacher is a relatively young teacher and just needs to be re-educated and reminded what needs to happen in the classroom in order for it to be a safe learning environment,’ he told KENS." No, It’s not about experience or re-education. This teacher has no common sense.

A 17-year-old student was allowed to lose consciousness during an asthmatic attack while the school nurse looked on. Why? His mother had not signed a form authorizing use of an inhaler. It gets worse. The the story says the nurse not only failed to call an ambulance, she locked the door of the office with the boy inside. The school’s response? “Deltona High School and Verona County officials stand by the nurse's decision.” The kid would have been better off had he been in the street. Bystanders would have at least called 911.

At a school field day, two girls were sunburned to the extent that their mother took them to a hospital that evening. It was raining that morning and their mother did not apply sunscreen. When the sun came out later that day, the girls were not permitted to use sunscreen. Why not? According to a published report, “The school district's sunscreen policy, which forbids teachers from
applying sunscreen to students, and only allows students to apply it to
their own bodies if they have a doctor's note authorizing it, is based
on a statewide law.” No one thought to take the children out of the sun or call their mother to come to apply sunscreen. Oh by the way, one of the girls has a type of albinism. Tell me please, how easy do you think it is to obtain a doctor’s note authorizing the application of sunscreen, a non-prescription substance?

In case you think that this is a uniquely American phenomenon, here’s a similar story from England. Pupils in a creative writing class were told to write a note to their mothers as if they had only a few hours to live. When he got home from school, one 14-year-old boy handed the essay to his mother who thought it was a suicide note and was understandably upset. The school apologized "for any distress."

What is going on here? A six-year-old is beaten up by his classmates at the direction of a teacher. What is the lesson for the “bully” and the other students? A nurse watches a child try to die from an asthma attack and does nothing. Two children are sunburned because a doctor’s note is required for the application of sunscreen. A suicide note as a creative writing exercise is understandably of great concern to a child's mother.

These teachers and administrators are supposed to be educating our young. And people ask me why one of my daughters has chosen to homeschool (or rather “unschool”) her two children.

Friday, June 22, 2012

A while back I wrote a blog
about a resident’s operative dictation that was incoherent and the pitfalls of
dictating. Here is another example.

The switch to electronic medical records has brought some
unintended consequences. We now have rapid turnaround of dictations at my
hospital. They appear in the electronic record within a couple of hours and
require verification by electronic signature. As is true of many documents that
appear on computers and the Internet, they sometimes are not read carefully.

It was electronically signed by the physician who dictated
it. I’m guessing that he did not proofread it. At least I hope not.

The name was changed to protect the innocent.

Dr. Balotelli found on
endoscopy a stomach full liquid with esophagitis. There was a 3 orifices in the
distal esophagus. There is a hiatal hernia sac, actually 2 of them; 1 led to
the antrum. Pylorus and duodenum of the hernia sacs are full with dark liquid
which were suctioned. The third compartment led to the small bowel. It did not
contain any contents. The hernia sacs
were friable and ulcerated. The mucosa in the antrum and pylorus were widely
open. The duodenum appeared normal. Since then, the patient is no longer nauseated
or vomiting. His NG output is minimal.

As far as I know, I am the only person who has actually read
this note. The entry was made a while ago and has not been corrected.

I used to use Dragon dictation. You must take great care
when proofreading because you tend to read what you meant to say, rather than
what Dragon thought it heard. I once dictated a letter of recommendation for a
student. Instead of Dragon typing "she is confident and poised," it
came out "she is confident and moist."

Does anyone really read electronic progress notes?

Do you know of any examples of dictations gone astray like
this? If so, please describe.

A slightly different version of this post appeared on Sermo yesterday. Most of the
comments suggested that the EMR would be the downfall of society as we know it.

Wednesday, June 20, 2012

By their own admission, medical hospitalists are
guilty of many types of unprofessional behavior says a recent paper
published ahead of print in the Journal of Hospital Medicine. A group of
researchers from the University of Chicago surveyed medical hospitalists from
three major Chicago area teaching institutions. The respondents themselves
rated each listed behavior on a professionalism scale. There were 77 responses
from pool of 101 hospitalists who were sent the questionnaires. The study asked
respondents to state whether they had either engaged in and/or observed
unprofessional conduct.

The key findings were as follows:

Most of
the respondents had engaged in at least one unprofessional behavior.

The
most common unprofessional behavior was [I hope you are sitting down.]
having non-medical/personal conversations, such as discussing plans for
the evening, in hospital corridors. [Gasp!]

Over
60% of these doctors admitted that they ordered a routine test as “urgent”
as a way of obtaining results more quickly. [Can you believe it?]

My
favorite is that 40% confessed that they had made fun of or disparaged the
emergency department team for missing findings. [Unreported but very
likely true is that 60% of those questioned committed another
unprofessional act, which was lying by claiming they had never made fun of
or disparaged any ED MDs. The only physicians I know who do not routinely
make fun of the ED staff are pathologists because they never deal directly
with the ED. Before all you ED docs get your panties in a knot, I am
certain all of you disparage all of us too.]

Other
alleged unprofessional behaviors were celebrating a blocked admission,
going to working when ill and texting during conferences.

Another interesting finding was that for every one of
the over 30 unprofessional behaviors listed in the questionnaire, hospitalists said
they had observed many more such behaviors than they admitted to participating
in.

Despite what many surgeons may have believed, this
survey shows that medical hospitalists are really pretty normal.

But I suspect there will be corrective actions for
these doctors at the three hospitals. A curriculum will be developed and
monitoring metrics will be established. Maybe listening devices will be placed
in hallways. These scandalous behaviors must be stopped.

A final note—this study was supported by grants from
two different sources.

Friday, June 15, 2012

Apparently a few years ago someone decreed that
“non-compliant” was no longer a politically correct term to describe patients
who did not take their medicines or follow instructions. The newspeak to use is
now “non-adherent.” This was recently brought to my attention by cardiologist-blogger
Dr. John Mandrola, who humorously blogged
about his own non-compliant-adherent behavior after a hand injury.

I googled “non-adherent vs. non-compliant” and found
references to the former used in medicine from as far back as 1998 but most
hits were from this century. I could not identify the origination of the switch
or why the term non-compliant was perceived to be judgmental.

I suppose compliant has a more submissive connotation, and
God knows, we should not consider patients as subjugated, but adherent really
means sticky as an adjective and follower as a noun. Is a patient who takes his
meds “sticky” or a “follower”? The difference between the two definitions,
compliant and adherent, is minor at best.

Who decides these things anyway? I don’t remember this being
discussed anywhere.

This phenomenon is not unique to the US. Public health
workers in the UK were recently informed that the use of the word “obese” could
be viewed as derogatory by obese people. The workers were told “that patients
may respond better if they are encouraged to achieve a ‘healthier weight.’” The
full story is here
and is worth reading if only for this amusing mixed metaphor uttered by an
opponent of the UK advice, “If you beat around the bush then you muddy the
water."

There is research on this subject. A 2012 paper from the journal Obesity
[soon to be renamed “Healthier Weight,” I guess] describes a survey of a lot of
people whose weight formerly would have been termed obese but now should properly
be called unhealthily weighted. The term fatness was rated as significantly
more undesirable than all others and excess fat, large size, obesity and heaviness were rated as significantly more objectionable
than the remaining terms, such as weight problem,
BMI, excess weight and the best of all, weight.

It’s not clear how just describing someone as “BMI” or
“weight” will get the message across, but then I didn’t perform the study.

Question: what do you do with a person who needs to achieve
a healthier weight but is non-adherent?

This post appeared on Sermo yesterday and
attracted 28 comments. As you might expect, most did not like the idea of
politically correct terminology.

Thursday, June 14, 2012

New York City’s Mayor Bloomberg has proposed
a ban on the selling of sugar-containing drinks in containers larger than 16
ounces in all types of eating establishments including street vendors, movie
theaters, delicatessens and even stadiums. The purpose is to limit sugar intake
and theoretically help people lose weight by saving them from themselves.

The plan has received mixed reviews with some calling it a
“nanny state” action. Also since a consumer can buy more than one 16 ounce
bottle at a time, detractors point out that the truly motivated sugar addict
will not be deterred. Supporters say that anything that limits sugar
consumption is good. A recent poll
shows that slightly more than half of New Yorkers think the idea is bad.

I don’t think it will have any impact on the general public
at all. There is no proof that obesity is related to the size of a drink
container. One wonders if the mayor is simply grandstanding.

But more importantly, the mayor could have far more
influence if he addressed something he can control. That is the selling of
sweetened sodas and junk food at the 11 acute care hospitals owned and run by
the city serving mostly indigent New Yorkers.

On nearly every floor of the city owned hospitals, vending
machines are stocked with mostly non-nutritious snacks and sodas containing
sugar. Cafeterias and coffee shops feature similar fare.

If the mayor wants to do something constructive about
obesity, he should mandate that his hospitals lead the way and stop giving obese
patients and those with diabetes access to products that are not good for them.
It makes no sense to counsel a hospital patient about a diabetic or weight-loss
diet and then provide that same patient a vending machine full of junk 100 feet
from his hospital room.

While he’s at it, the mayor should ban the sale of junk food and sodas
in the more than 40 other private and not-for-profit hospitals in the city’s
five boroughs.

That would be a real obesity prevention program, not a
publicity stunt.

Wednesday, June 13, 2012

The
cumulative attrition rate of general surgery residents has been holding at
about 20%, a figure that has been steady for nearly 20 years. This figure is
higher than that of most other medical and surgical specialties.

The
institution of the 80 hour work week was heralded as a solution to the problem
of attrition. Students who in the past wanted to be surgeons but had shied away
from surgery were thought to be more likely to enter the field. The presumption
was that in the old days, surgery was considered daunting due to the excessive number
of hours worked.

If the
attrition problem was just about the hours worked, one would expect the attrition
rate to be less now; so far, it is not so.

The latest study of this problem points
out that attrition occurs early in the course of training and is not related to
the gender of the resident or any other specific factor.

So
why do so many surgical residents drop out or wash out?

I
believe a major cause is that medical students do not understand what surgical
residency training is really like. In some schools, third-year clerkships are
as short as 4 to 6 weeks, and part of that time may be devoted to clinic or
subspecialty rotations.

Many
medical schools limit the amount of night call that a student is required to
take to one night per week with the proviso that the student is only to be
awakened if something interesting is happening on the service. Some schools
define night call as ending at 11:00 p.m.

Limited
exposure such as this gives the students an unrealistic picture of what a surgical
residency is like. This can result in disillusionment when the prospect of 4
years of real general surgery residency hits home. [I am counting only 4 years because
the new Accreditation Council for Graduate Medical rule limiting first-year
trainees to a maximum of 16 consecutive hours of work will simply postpone the
problem for a year.]

An
interesting paper from
2006 noted that a significant number of applicants to general surgery residency
programs were “relatively uncommitted” to the field of general surgery compared
to applicants to other surgical disciplines.

The
combination of unrealistic expectations and lack of commitment leads to residents
resigning or performing poorly.

This
problem has implications for both the program and the departing resident. When
a resident leaves a program, a competent replacement may not be easy to find,
and the departing resident often finds he has wasted a year or more of his life
because he often ends up in a non-surgical specialty.

True to my
style, I am good at pointing out problems but not so good at finding solutions.